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October 9, 2017 – Neurology clinic starts for earnest….

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Our days of neurology clinic last week had been “unadvertised,” meaning that they hadn’t been officially announced to the community and were filled primarily with patients who were being referred to us from other FAME doctors or were patients who had been contacted directly to see us prior to the community referrals. As I’ve mentioned before, I have worked for the last several years with a very outreach team here at FAME who typically work for a month or two prior to our arrival making announcements in the community of the dates that we will be at FAME to conduct our clinic. They have been very effective in getting us lots of patients, but almost more importantly, appropriate patients that have real neurologic disease and who are appropriate for us to see. As we charge a single low fee to see us, there has been an issue in the past of patients coming to our clinic to receive their care this low all-inclusive price and since we’re subsidizing the neurology clinic with limited funds, it’s imperative that we see only neurology patients and to make sure that our funding goes towards these patients.

Monday morning waiting to be seen in the neurology clinic

After morning report, we all walked over to the night office and emergency room area where we hold our neurology clinic every day to begin our week of “advertised” clinics for the community. It’s often hard to tell what type of reception we will have as there are so many things that affect our volume – harvest, rains, politics and whatever else might be going on in the country. Several years ago, I arrived to the country in the midst of news of a faith healer in the Loliondo region north near the Kenyan border who was curing everything from diabetes to cancer to HIV by merely drinking his tea made from a local plant. He was known simply as Babu and it had created somewhat of a national crisis as everyone was taking whatever form of transportation they could to reach him and there were miles of traffic in an area where there are no services and the roads are poor. Many people died along the road on their way to visit them as they had stopped their medications in anticipation of their being cured of whatever ailed them, Babu at one point got onto the radio to urge everyone to remain on their medications to prevent further catastrophe. On my way to Arusha from the airport I saw numerous buses, safari vehicles and trucks packed with people on their way to visit Babu.

Neena and Baraka evaluating a patient

Sara seeing a gentleman with a spinal cord injury

Needless to say, this greatly reduced the number of people coming to the clinic for a short while until the entire fiasco came to light and it was clear that Babu couldn’t treat what it was said he could. Picking up the pieces after the Babu story stressed many dispensaries and hospitals as the people who traveled to see him all needed care on their return trips home. At one point, the government was actually considering using Babu as a travel destination as news spread outside the country and there were individuals from Europe and other African countries traveling here for a cure, It was a brief, but dark episode in the history of healthcare here.

Neena and Emanuel evaluating a patient

Whitley and Baraka evaluating a patient

Thankfully, nothing similar was going on now so that all the patients who needed care were finding the right doctors to provide it. And as far as our neurology clinic went, we soon discovered that there was a mob outside the night office already waiting for us despite the early hour and the fact that the main clinic hadn’t even opened yet for the day. Patients travel from very far distances often to see us here, many from the Loliondo district where Babu had been peddling his tea as well as some from Dar es Salaam. It is impossible for us to see everyone who shows up to see us the first day so we hand out numbers to patients and usually limit the number we see in a single day to around thirty. That means that some have to come back the following day and we let those know as early as possible so they don’t sit around for the entire day waiting only not to be seen in the end. It never fails, though, that we end up seeing more patients than we’ve intended as there are usually a few consults from the outpatient clinic and I know for a fact that extra charts always appear in the stack to see as the staff have a hard time turning people away. Somehow, we always manage to finish, though they are very long days and a bit hectic at times.

Neena evaluating a patient with probable schizophrenia

Sara and Whitley working with Dr. Ken

The baby with hydrocephalus was still in the ward sadly as the family just couldn’t really decide what they wanted to do. At one point, they had indicated that wanted to take the baby home which meant that it would certainly die given its situation. His head circumference hadn’t changed, but he didn’t seem to be quite as responsive as before and time was surely running short for anyone to successfully intervene meaning that it would make a difference in the eventual outcome for the baby. Dr. Ken was working with us today and at one point during the day I chose to discuss the situation with him and what was appropriate here given the circumstances. It was the family’s right to determine what they wanted to consent to or not, and without a government services such as a child protection agency, the ones who would surely intervene at home, it was impossible to tell the family that they couldn’t do what they chose to do. Forcing them to treat the child without some sort of public support system to absorb the costs of raising a very likely mentally and physically impaired child wasn’t appropriate either so given all of the facts, it was really the family that would have to make the ultimate decision here and there was no way to get around that inevitability as hard as it was to accept. If we were imposing our views, we could only hope that they would decide to bring the baby to Arusha to be treated, but the decision was not ours and there was not right decision here.

Dr. Ken demonstrating his neurological examination

Neena performing an occipital nerve block

A similar situation occurred with Sara’s last patient of the day, a very small child of five months or so who was severely malnourished and encephalopathic. The baby had been seen initially in the outpatient clinic and recommended for admission, but the mother chose not to do so and somehow was sent to us to evaluate the baby neurologically. The baby was very, very emaciated and based on the history had some degenerative process that it would very likely succumb to and nothing we could do was going to change that. The baby had been admitted to Haydom Hospital somewhere south of here, but despite the best efforts of the care team, had not improved and so the mother was very skeptical that anything we could do was going to change the future. At first we were very insistent that the baby be admitted, but by the end of the visit, we were quite sympathetic of the mother in the decision she was making and told her that there was no right answer given the circumstances and that we supported her in whatever decision she was going to make. These are obviously very difficult situations, but the most important thing from our standpoint is not to impose our values and you must always remember that.

Sara working with Dr. Ken on his neurological examination

Sara evaluating the last a patient of the day, a malnourished and encephalopathic baby

We worked the day with Dr. Ken, whom I have worked with many times before and is now an Assistant Medical Office rather than a Clinical officer as he was sent back to school for the additional training, something that is completely sponsored by FAME.

We finally finished clinic around 5pm and made it back to the house in time for sunset while Sara, Neena and Whitley entered all the patient data for the day into our databases that we’ve been keeping for several years. It was dinnertime after that and then a relaxing evening in the Raynes House. Sara needed to work on her talk that she would be giving the following morning on the pediatric neurology examination and the rest of us worked on various projects.